Case Presentation

Alexandra Janda

August 18, 2020

Body CT/MRI – RAD4005

Dr. Larry Kramer

McGovern Medical School

Clinical History

• CC - 57yo postmenopausal G1P1 presents from OSH with complaints of left leg swelling x3d, no pain, redness or difficulty walking

• PMH – prior MI and RLE DVT• PSH – none• Meds - Asa 81 mg• Allergies – NKDA• SH - 10 pk/yr, quit 5 months ago• FH – denies• Review of systems

• Unintentional weight loss (12-15 lbs in 3-4 weeks), abdominal bloating/distension lack of appetite, weakness

• Denies fever, chills, CP, palp, SOB, cough, N/V, bowel changes, abdominal pain, vaginal bleeding, discharge, myalgia, arthralgia

McGovern Medical School

Physical Exam

• BMI 18

• Firm, largely distended abdomen

• LLE below knee twice as large as RLE • No erythema, tenderness, or edema

• 2+ pulses

• Normal vaginal exam

McGovern Medical School

Imaging from OSH

• CXR - 7/29/2020

• CTAP w/contrast - 7/29/2020

• Duplex Venous Doppler - 7/29/2020

McGovern Medical School

Chest Radiograph

No acute cardiopulmonary process

McGovern Medical School

Axial Plane

CT AP w/contrast

McGovern Medical School

CT AP w/contrastCoronal Plane

McGovern Medical School

CT AP w/contrastSagittal Plane

McGovern Medical School

Solid ComponentsCystic Components

Enhancing Septations

Axial Plane

McGovern Medical School

Normal

Sagittal PlaneCoronal Plane

PatientPatient Normal

McGovern Medical School

What else do you see?

Coronal Plane

Aortic Thrombus

McGovern Medical SchoolAxial Plane

L Common Iliac Vein Thrombus

McGovern Medical SchoolAxial Plane

L External Iliac Vein Thrombus

McGovern Medical School

CT AP w/contrast

• CTAP w/ - large complex cystic peritoneal mass, likely ovarian neoplasm• Large complex confluent multilocular cystic mass occupies nearly half the

entire peritoneal cavity of the mid to lower abdomen measuring 32x27cm

• Eccentric L sided distal abdominal aortic plaque or mural thrombus 5.4 cm in length which causes 50-60% narrowing of the aortic lumen

• Extensive LLE DVT expanding the L external iliac artery

McGovern Medical School

Assessment

• 57yo postmenopausal women with a PMH of MI and prior RLE DVT who presents today with complaints of LLE swelling and abdominal distention who was found to have a large complex mass on imaging suspicious of GYN malignancy and a large LLE DVT.

McGovern Medical School

Orders for pelvic mass

• CBC• WBC – 15.4 (H), platelet - 546 (H), RBC 2.5 (L), hgb – 7.4 (L)

• CMP - normal• Mag – 2.7 (mild H)• Phos – 2.5• Lactic Acid – 1.4• CEA -0.4 • CA-125 – 3361 (H), (Normal <35 U/mL)• CA 19-9 – 268 (H), (Normal <34 U/mL)• PT/PTT – 15.3 (mild H)/31.3• COVID – positive!!

McGovern Medical School

Exploratory Laporotomy – 8/3/2020

• Ex/lap, bilateral salpingo-oophorectomy, lysis of adhesions, omental biopsy• Bilateral large adnexal masses – L extending up to her xiphoid (30cm) irregular

and multicystic – ruptured upon entry• Tube and ovary sent for path – high grade carcinoma

• R ovary and tube were socked into the posterior cul-de-sac about 20 cm, irregular and multicystic

• Large conglomerate of tumor arising from cecum/appendix that was eroding the abdominal wall

• Terminal ilium going into the mass

• Omentum and transverse colon seemed to be involved

McGovern Medical School

Differential Diagnosis

Postmenopausal

Primary cecal appendiceal carcinoma with ovarian metastases

Synchronous primaries of GI and GYN primary malignancy

Premenopausal

Molar pregnancy

McGovern Medical School

Pathology Findings

Detailed Report:

• Left tube and ovary• High grade serous carcinoma• Tumor size 24.0 cm• Stage pT3c Nx

• Right tube and ovary• High grade serous carcinoma• Tumor size 30.4 cm• Stage pT3c Nx

• Peritoneal nodule• Metastatic high-grade serous

carcinoma

• Omentum• Metastatic high-grade serous

carcinoma• Largest metastatic nodule 3.5 cm

Final path stage IIIC high grade serous carcinoma of the ovary

McGovern Medical School

Treatment Plan

• Recommend colonoscopy to evaluate for secondary malignancy

• If it is only ovarian cancer• Chemotherapy - Carboplatin/Paclitaxol x3

• Interval debulking if patient is medically stable

McGovern Medical School

Comparing H&P to imaging

DVT• History

• 3-day history of LLE swelling, prior R DVT

• Physical Exam• LLE 2X size of RLE

• Imaging• Doppler and CTAP show

extensive active DVT

Abdominal Mass• History

• Weight loss – 15 lbs in 3-4 weeks

• Physical Exam• Distended, firm abdomen

• Imaging• CT shows large complex confluent

multilocular cystic mass

• Surgery• Bilateral large adnexal masses• Large conglomerate of tumor arising from

cecum/appendix

McGovern Medical School

ACR Appropriateness Criteria

McGovern Medical School

Imaging Costs at Memorial Hermann

Charge to Insurance

Insured patient responsibility

Uninsured

Chest X-ray (1 view) $683 $250 $246

CT Abd/pelvis w/con $7,998 $480 $2,879

Unilateral Duplex US $1,273 $112 $458

Total $9,954 $842 $3,583

Additional Cost in Imaging:Insured: $2,377

Uninsured: $4,311

McGovern Medical School

Take Home Points

•Cancer doesn’t always present with a chief complaint of unexplained weight loss

•CT is the primary modality for ovarian tumor staging and diagnosis of recurrence

• Imaging is expensive!

McGovern Medical School

References

• https://acsearch.acr.org/docs/69378/Narrative/

• https://www.memorialhermann.org/patients-caregivers/memorial-hermann-charge-master/

• https://www.labpedia.net/tumor-marker-part-7-ca-125-and-ca-19-9/

• https://radiopaedia.org/cases/normal-ct-abdomen?lang=us

• https://link.springer.com/chapter/10.1007/174_2017_43

• https://www.ultrasoundpaedia.com/normal-dvt-leg/

• Stacey A Funt, Lucy E Hann, Detection and characterization of adnexal masses, Radiologic Clinics of North America, Volume 40, Issue 3, 2002, Pages 591-608, ISSN 0033-8389, https://doi.org/10.1016/S0033-8389(01)00009-4.

Questions?